How to Document Medical Necessity

Editor’s Note: Cutting through the red tape to make certain that you get paid for every dollar you earn has become more difficult than ever, particularly in our current climate of health care reform and ICD-10 transition. The ACEP Coding and Nomenclature Committee has partnered with ACEP Now to provide you with practical, impactful tips to help you navigate through this coding and reimbursement maze.

Question: How do I document medical necessity?

Answer: Medical necessity is defined by Medicare as “health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.” The American Medical Association has a similar but longer definition. To document medical necessity, the chart must convey the reasons diagnostic and treatment decisions were made. Some situations are very obvious, such as an X-ray on an injured ankle. However, some situations are not, such as the back pain patient requiring an MRI. If the clinician documents that there was a concern for cauda equina syndrome, the medical necessity for the MRI now becomes clear, but without that notation, an auditor might deny payment for a higher-level visit because of the lack of medical necessity for the MRI. All patient encounters must fulfill medical necessity. Make sure your documentation supports the actions you take.

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2 Responses to “How to Document Medical Necessity”

As I consider 2017 CPT code description changes to Non-face-to-face prolonged service codes 99358 and 99359 it seems codes may be appropriate for my ED physicians, in some cases, such as; discussions/information through phone conversations with another provider before the patient arrives in ED, or phone conversations and reports after the patient has been transferred to a higher level of care.

Code 99358 and 99359 are not applicable to emergency medicine due to the fact that the codes are for prolonged service beyond the typical service time. Emergency department codes do not have typical service times.